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DO YOU HAVE INFLAMMATION?

Date of Birth
Email:
Do you have IBS symptoms such as gas, bloating, diarrhea, constipation?
yes
no
If you answered yes, what symptom(s) do you have?
Gas
Bloating
Diarrhea
Constipation
Diarrhea and constipation
Other
n/a
If you said other, what other symptom(s)? If none, type n/a
Do you have skin concerns?
yes
no
If yes, select which skin concerns you have:
Acne
Rosacea
Eczema
Hives
Other
n/a
If you answered other, what other symptom(s) do you have? If none, type n/a
Do you have swelling?
yes
no
Do you have trouble staying asleep at night?
yes
no
Do you have restless leg syndrome?
yes
no
Do you have an autoimmune condition?
yes
no
If you answered yes, which autoimmune condition do you have? Type n/a if none
How many servings of vegetables do you eat in a day?
0
1-2
3-4
More than 4
How many servings of fruit do you eat in a day?
0
1-2
3-4
More than 4
How many 4-6 oz servings of meat do you eat in a day?
0
1-2
3-4
More than 4
Do you eat fast food?
yes
no
If you answered yes, how many times do you eat fast food in a day?
0
1-2
3-4
more than 4
n/a
How many servings of added sugar do you eat in a day?
0-5g
5-10g
10-15g
15-20g
20-25g
What type of exercise do you do?
None
Cardio
Weight Resistance
HIIT
A combination
If you exercise, how many days a week?
1
3
5
7
n/a
If you do cardio, for how long?
10 minutes
20 minutes
30 minutes
60 minutes
More than 60 minutes
n/a
If you do weight resistance, how long?
10 minutes
20 minutes
30 minutes
60 minutes
More than 60 minutes
n/a
If you do HIIT training, for how long
10 minutes
20 minutes
30 minutes
60 minutes
More than 60 minutes
n/a
If you are female, do you still have your menstrual cycle?
If you are female and in menopause, do you have hot flashes?
yes
no
occasionally
n/a
Do you know if you have any food sensitivities?
yes
no
Would you be willing to take a food sensitivity test?
yes
no
If you answered yes, please list your known food sensitivities, if none please type n/a
Do you take Vitamins and/or mineral supplements
yes
no
If yes, which vitamins and/or mineral supplements do you take?
Multi-Vitamin
Vitamin D
Vitamin C
Vitamin B-Complex
Vitamin K
Vitamin E
Iron
Calcium
Zinc
Magnesium
Probiotics
Prebiotics
Omega 3
n/a
Do you suffer from fatigue?
yes
no
Do you wish you could feel better?
yes
no
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